Successful endodontic solutions for decayed teeth – Dr Nalin Karunaratne

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  Posted by: Dental Design      5th June 2019

Dr Nalin Karunaratne is a dentist in Ashford, Kent, with an interest in endodontics. Here, he presents an interesting case, where an elderly patient with a complex medical history required multiple root canal treatments.

Initial presentation and patient background

My patient was a 62-year-old lady with Parkinson’s disease. She also had emphysema and osteoarthritis. This lady was referred from another local practice as she was suffering from pain and food packing on her lower left side for the best part of a year and no solution had been found. She had been to seea dentist who had advised extractingall three teeth,but,seeking a second opinion, the patient was initially referred to our implant surgeon.

A periapical radiograph (see Figure 1) indicated large distal cervical radiolucencies involving the pulp on LL5, 6 and 7. On the LL6 it extended into the furcation.

Figure: 1

Our implant surgeon and I first looked at a fixed conventional bridge between the LL5 and LL7, accepting that LL6 could not be saved. However, the prognosis of a bridge in a high-loading area, in a patient with established toothwear from grinding due to stress on two root-treated abutments, was guarded at best.

She did not want a denture.Therefore, we decided to try root-treating the LL5 and LL7 with urgency and the LL6 would be replaced with an implant thereafter.

The patient’s Parkinson’s disease was well controlled and she had full capacity to consent. Everything was explained verbally and a written explanation and summaries were provided and signed, making for robust informed consent.

Treatment pathway

The first objective of the treatment, after a full examination, was to root-treat the LL5 and LL7. Due to the long-standing infection and the clinical burden of treating two teeth, we decided this would be tackled in two long visits.

First, I gained access. A rubber dam was used to isolate both teeth. After full caries removal, there was still enough coronal tooth substance left to support two crowns. This would not be straightforward, however, given the extent of carious breakdown.

The LL7 was the more decayed of the two, so to successfully isolate this with the rubber dam was more challenging. Therefore, a gingivally approaching clamp was selected alongside ‘wash’ impression material to gain the best possible seal.

The LL5 presented with a single canal as expected and the LL7 had two mesial canals and one distal canal. Patency was established with a size 10 K-File. Copious irrigation was carried out with Parcan solution (3% sodium hypochlorite) between instruments with regular recapitulation with the K-File to ensure that the canals were not blocked.

Since they were not particularly narrow in diameter, canal preparation was done with the COLTENEHyFlex™ EDM OneFile of ISO 25 apical size, usingCanal+ as lubrication.

Using an electronic apex locator it was found that LL5 had a 23mm working length. For the LL7, the distal canal was 19.5mm, mesiolingual canal was 21.5mm and mesiobuccal canal 21mm.

At the following visit, obturation was completed with bespoke master apical cones, ROEKO Guttapercha Points (ISO size 25), to a good radiographic finish after drying the canals with the corresponding ROEKO Paper Points (both from COLTENE).

We elected to protect the teeth as soon as possible, so cuspal coverage definitive restoration was begun straight away.

The LL5 was restored with an e-maxonlay, bonded with COLTENE BRILLIANT EverGlow™ universalcomposite and the LL7 was restored with a full gold crown, cemented with conventional glass-ionomer cement.

The LL6 was deemed to be unrestorable, so it was extracted and replaced with an implant by our implant surgeon.


The patient was delighted with the result, which can be shown on the radiograph (see Figure 2).

Figure: 2

She was very grateful to both clinicians, as she could now eat, drink and function without pain.

In modern dentistry, ease is everything. COLTENE HyFlex™EDM files are a superb one-file system that will help in all but the most aggressive curvatures.
The matching CanalPro™Cordless Handpiece, also from COLTENE, with its angled head, is fantastic for access in even the most complicated cases. Endodontic treatment becomes more efficient; you use fewer files and suffer less hand fatigue. For a single file system, it is particularly flexible too. As for the more marked curves, that’s when the COLTENE HyFlex™CM (controlled memory) multiple file protocols come into their own.


To find out more about COLTENE, visit

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